All lesbian, gay, and bisexual (LGB)* people are not the same. I’ve long been an advocate that it’s not “the LGB community”, it’s “the LGB communities“. Even within just the lesbian “community”, there are subgroups. Everyone has different experiences, needs, and expectations. There is no one universal experience, and no monolithic community.

The easiest example is gender nonconformity. Within lesbian and female bisexual communities, for example, there are women who dress and act more masculine (“butch”) and women who dress and act more feminine (“femme”). The same is true for gay and male bisexual communities. Another example is “coming out”. While it’s a common experience, it’s not universal. I myself never had to “come out” to my family because my family was very accepting.. Bisexual people who date/marry opposite sex partners may also not choose to come out.

Despite differences, we know that there are some generalities about LGB communities. We know that LGB people, as a whole, have higher rates of depression than their straight peers. But we also know that not all LGB people have depression. Could gender nonconformity be the key?

Portrait of a boy, c. 1800. A boy who looked like this might well end up with depression after being teased and bullied.

Today’s study looked at depression, gender nonconformity, and LGB status among young adults in the United States. They used data from the Add Health study. Add Health was a study that started in schools and continued through until the participants were up to 32. The participants in today’s study were age 18-32. 86.7-93.1% of the sample (women-men range) were heterosexual. The rest were mostly heterosexual, bisexual, mostly lesbian/gay, or lesbian/gay. Depression was measured with a validated scale. Sexual orientation was rated on a Kinsey-type scale. And gender non-conformity was measured with a scale of activities, including team sports, religious activities, video game use, housework, and social activities.

What were the results?

At first, it looked like all the non-heterosexual participants were at higher risk for depression. Bisexuals had more depressive symptoms than lesbian and gay participants. However once they controlled for gender nonconformity, lesbians and gay men did not have more depression symptoms than heterosexuals. Bisexual participants continued to have higher rates of depression and controlling for gender nonconformity.

Who tended to be gender nonconforming? Young men were more nonconforming than young women. Lesbians and gay men were more nonconforming than all the bisexuals (including mostly straight and mostly gay), who were about as nonconforming as straight participants.

And the depression? Young women were more depressed than men. Black, Latino, and Asian participants were also more likely to have it. The same was true for those with low parental education levels and families with financial problems. Participants who were gender nonconforming reported more symptoms of depression than those who were conforming.

Lastly, the researchers looked at whether that depression held over time. Gender nonconformity did not predict depression in the future. Bisexuals, lesbian, and gay young adults were also not at risk for future depression; only depression in the moment. However individuals who identified as mostly heterosexual continued to have higher rates of symptoms. Individuals who are Black, Asian, female, had low parental education levels, or severe family financial problems, continued to have depression symptoms.

What does this really mean?

LGB young adults as a whole continue to be at higher risk for depression. However, that risk appears to mostly be an effect of gender nonconformity as a young adult. Those who are gender nonconforming as young adults are at higher risk for depression as young adults, but six years later that risk goes away. Why? Gender nonconformity is visible, and likely to result in the individual being a target for discrimination, which can result in depression. But then why doesn’t it continue six years later? Either the discrimination reduces (teenagers can be notoriously mean to each other), or the individuals develop coping skills or move into a more accepting community.

Additionally, bisexuals and mostly heterosexuals are at higher risk for depression than lesbians and gay men. Why? Well, it might be because they can “hide” and look heterosexual. That means they don’t need to “come out”. But it also means there’s less acceptance and acknowledgement of their orientation. That could have big effects.

What do we do with this information?

First, we can keep an eye out for the gender nonconforming young adults in our communities, whether they’re straight, bisexual, gay, or somewhere in between. We can support them when they need it. And second, we can create a more accepting environment. The less discrimination and the more acceptance of gender nonconformity, the less depression we are likely to see. We can make the world a positive place to be for everyone.

*: Please note that although today’s article does not use the word “cis” throughout despite the implication. The study in question examined cis individuals. However in my language, I use “men/male” and “women/female” to refer to gender identity, not biologic sex. So the general statements I make are intended to be inclusive of both cis and trans individuals, who can be lesbian/gay, bisexual, or straight.

The Greek letter Psy is often used to symbolize psychology or the APA.

The American Psychological Association has released a 55-page document detailing guidelines for psychologists treating transgender and gender non-conforming individuals. To my knowledge, this is the first such document the APA has published. It’s a huge milestone in trans mental health care.

APA guidelines provide standards for both trainees and practicing psychologists on the expected conduct of psychologists. They’re used in both introductory and continuing education.

In this document, the APA lists out the following guidelines (note that TGNC stands for “transgender/gender non-conforming”):

Psychologists understand that gender is a non‐binary construct that allows for a range of gender identities and that a person’s gender identity may not align with sex assigned at birth.

Psychologists understand that gender identity and sexual orientation are distinct but interrelated constructs.

Psychologists seek to understand how gender identity intersects with the other cultural identities of TGNC people.

Psychologists are aware of how their attitudes about and knowledge of gender identity and gender expression may affect the quality of care they provide to TGNC people and their families.

Psychologists recognize how stigma, prejudice, discrimination, and violence affect the health and well‐being of TGNC people.

Psychologists strive to recognize the influence of institutional barriers on the lives of TGNC people and to assist in developing TGNC‐affirmative environments.

Psychologists understand the need to promote social change that reduces the negative effects of stigma on the health and well‐being of TGNC people.

Psychologists working with gender questioning and TGNC youth understand the different developmental needs of children and adolescents and that not all youth will persist in a TGNC identity into adulthood.

Psychologists strive to understand both the particular challenges that TGNC elders experience and the resilience they can develop.

Psychologists recognize that TGNC people are more likely to experience positive life outcomes when they receive social support or trans‐affirmative care.

Psychologists strive to understand the effects that changes in gender identity and gender expression have on the romantic and sexual relationships of TGNC people.

Psychologists seek to understand how parenting and family formation among TGNC people take a variety of forms.

Psychologists recognize the potential benefits of an interdisciplinary approach when providing care to TGNC people and strive to work collaboratively with other providers.

Psychologists respect the welfare and rights of TGNC participants in research and strive to represent results accurately and avoid misuse or misrepresentation of findings.

Psychologists seek to prepare trainees in psychology to work competently with TGNC people.

This is all excellent.

There is a history of psychologists attempting to change gender identity through conversion therapy or other coercive means. The APA’s statement, in effect, states very strongly that attempts to change gender identity should not be attempted. Instead, the APA is embracing the ethical treatment of transgender people and of affirming transgender and gender non-conforming people.

Do these guidelines mean anything for you if you’re receiving therapy? Possibly. Talk with your therapist, whether you’re trans or cis, to make sure they’ve seen the updated guidelines. If you’re receiving therapy that is not within these guidelines, consider talking with your therapist about these guidelines or seeking another therapist.

Being a gender or sexual minority (GSM) is not only difficulty and tricky for patients — it can also be a challenge for medical providers. Medicine can be a particularly conservative field, depending on location and specialty. Lives are, after all, often at stake.

Despite recent advances it appears that some 40% of lesbian, gay and bisexual medical students are hiding their sexual minority status in medical school. Among transgender medical students, 70% were hiding their identity. All because of fear of discrimination.

That fear has been, and still is, warranted. From medical providers transitioning and losing their practices, to medical students losing their residency slots, to LGBT health student organizations fighting to exist, LGBT providers face similar discrimination as our patients. Similar happens for other gender and sexual minority health care providers, though we lack statistics. At a meeting of kink-identified mental health care providers, one attendee noted a high level of vulnerability for the clinicians. Being “outed” could lose them their jobs or even trigger legal action.

To some extent, discretion among health care providers is warranted. Most people don’t want to know about their clinician’s (or coworker’s) personal lives. And most GSM providers don’t actually want to share those most intimate details. It’s where the line is that can be distressing — how much information is too much? Can I discuss my wife when other women clinicians are discussing their husbands? How exactly do you notify your fellow clinicians or patients about a change in gender pronouns or name? How can a clinician use information gained from intimate encounters to help patients, without revealing too much? It’s a balance we constantly seek. Sometimes mentors are there and can help. Other times we figure it out as we go along.

Yet we bring a lot to the table, as minorities. Like many racial and ethnic minorities, there are pressures and issues that affect GSM people more than the majorities. We bring that knowledge with us to the research we choose to perform, the communities we participate in, and each and every patient encounter.

We as clinicians and future clinicians need to have the support in order to be appropriately open about our gender and sexual minority status. Our patients and clients must know they can be safe and honest with us so they can receive the most complete and respectful care possible.

I’m proud to say that my medical school has been accepting and supportive of its gender and sexual minority patients, and that clinics in the area of my medical school are seeking to expand their care to be more inclusive of LGBT patients. Support exists for both those seeking medical care, and those seeking to provide that care. It’s only the beginning.

One of the premier medical journals, the New England Journal of Medicine, regularly has perspective/opinion pieces. For a pre-med like me, they can be some of the most valuable pages in the journal — they can be windows into medical practice, public policy and the study and practice of medicine. I read them regularly, since my wife got me a subscription to NEJM. Most aren’t related to gender and sexual minority health, so I haven’t addressed them here much. But in the April 10th edition of NEJM, a treasure! Gilbert Gonzales did a good summary of the intersection between same-sex marriage and health.

Many health journals, including NEJM, tend to live behind a pay wall. This particular article, thankfully, is not. But in the interests of public knowledge and discourse, I wanted to summarize some of the interesting points in this article. A heads up: this is a distinctly United States-focused article.

Despite recent advances, roughly 60% of the US population lives in a state that prohibits same-sex marriage

Discriminatory environments lead to poorer health outcomes. Example: LGBT people in states that ban same-sex marriage have higher rates of depression, anxiety, and alcohol use than straight/cis people in the same states. By the same token, states where same-sex marriage (e.g., MA and CA) was legalized show a drop in mental health care visits for some GLBT people (e.g., gay men).

Legalizing same-sex marriage improves access to health insurance for both same-sex spouses and children of same-sex parents.

Time for the monthly summary of the latest gender and sexual minority, and sexuality, related news!

The American Heart Association released a consensus that physicians should counsel people about resuming sex after a heart-related illness (e.g., heart attack, stroke, pacemaker installation). Apparently physicians have not be doing that. Oops! More information here.

Risk factors for developing PTSD (post-traumatic stress disorder) after exposure to a traumatic event have been further explored in adolescents. 61% of teens in this study were exposed to a potentialy traumatic event, but only 4.7% of the teens in the study actually developed PTSD. Risk factors included: previous diagnosis of a mood or anxiety disorder, being female, and the type of event. Interpersonal traumatic events (e.g., being raped or assaulted by another person) were associated with a higher risk of PTSD. Why bring this study up? Because GSM youth are at high risk for traumatic events! More info.

Virginia Johnson passed away due to natural causes. She was one half of the Masters and Johnson team that did pioneering work on sexuality in the 1960s. Condolences to her friends, family and loved ones. More info.

The X chromosome may have a role in sperm production. Not at all surprised by this – after all, the idea of the X chromosome as the “female” chromosome and the Y chromosome as the “male” chromosome are based in human perception, not pure biology. More info.

Female survivors of childhood sexual abuse may benefit from writing about their experiences. A study found that female survivors who specifically wrote about how the abuse changed the way they thought about sex had improved sex lives. Abstract.

PSA, prostate-specific antigen, may be useful as an indicator of testosterone level. While PSA’s usefulness as a screening tool for prostate cancer is still under debate, this other use is an interesting idea. It’s not currently in use for detecting low levels of testosterone, but it might be in the future. Cool! Abstract.

The average penis size has been determined. Again. Sorta. This study was internet, self-report based. So who really knows? This study reports that the average erect penis is 14.15 cm (5.57 in) long with a 12.23 cm (4.81) circumference. The racial makeup and age of the sample was not reported in the abstract. Abstract.

Sex addiction does not appear to be an addiction, according to a study out of UCLA. Interesting and not altogether surprising. Press release.

What is Open Minded Health?

OMH is dedicated to providing information about gender and sexual minority health. Posts are a mix of the latest research, activity risk reduction tips, and the latest news.

This blog is definitely not suitable for children, and probably not work safe. It contains descriptions of sexual activities that may disturb some readers.

Also please be aware: I am not a doctor. OMH does not provide health care advice - the information here is to be used as information only. It does not substitute a visit to your health care provider. When in doubt, please ask your health care provider.

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